Necrotizing Fasciitis in a Type II Diabetic Patient

Necrotizing Fasciitis in a Type II Diabetic
Patient: A Limb Salvage Case Report
Amy Reeter DPM, Jason Mendivil BA, MS-4, Robert Frykberg DPM,
MPH
Introduction- Necrotizing fasciitis is a severe
progressive soft tissue infection involving the
subcutaneous fat and deep fascial layers (3). It
results in extensive tissue necrosis (7). It has also
been associated with a mortality rate of about 50%
(5). Patients typically present with non-specific
symptoms hard to differentiate from cellulitis or an
abscess (8). Tissue crepitus or bullae and toxic
patient condition, which are distinguishing factors of
necrotizing fasciitis, are not always seen early in the
course of the infection (6). Diabetes is one of many
risk factors that increases mortality for a patient with
necrotizing fasciitis (4). Diabetes affects
microvascular circulation limiting blood supply to
superficial and deep structures because the
capillaries become “sugar coated” (3). This limitation
of blood supply decreases the concentration of
antibiotics in the surrounding tissue and therefore
debridement is crucial in the treatment course (3).
Necrotizing fasciitis is most often polymicrobial, so
early broad spectrum antibiotic use is a mainstay of
treatment for these patients (5).
Treatment and Outcome Cont.- On this same day
wound cultures were available and found to be betahemolytic strep. Antibiotics were switched to Ancef. 5
days after the 2nd I&D pt was taken back to the OR for
a TMA (Image 4), but it was left open due to the
extensive amount of tissue loss. The plan was to go
back later and close it primarily. Another wound
vacuum was placed intra-operatively. The next day
due to worsening of pt condition, WBC spiked to 16.2
and had previously been staying around 11, pt was
taken back to the OR and a Chopart’s amputation was
performed (Image 5), it was once again left open and
a wound vacuum was applied. The plan was made to
close this amputation the next week. The pt was
taken back to the OR 4 days later and the Chopart’s
amputation was closed (Image 6). The pt was
discharged from the hospital 4 days after the final
surgery and followed-up in clinic weekly until his
sutures were removed about 4 weeks later (Image7).
Pt was placed in a total contact cast until a prosthetic
could be made for him (Image 8). Pt now follows-up
in clinic and with the prosthetic department on a
regular basis to prevent problems in the future.
Patient Information- 49 yo diabetic male presented
to the ED complaining of a blister on the plantar
aspect of his right foot after running in a 5K race. Pt
was given supplies for dressing changes and told to
follow-up with podiatry. Pt presented to the podiatry
clinic 3 days later where he had a 7cm x 2cm wound
on the plantar aspect of his right foot with mild
cellulitis. Pt was placed on Doxycycline and
Ciprofloxacin and once again daily dressing changes.
Pt followed-up with podiatry 3 days later and he
complained he had been running a fever and that he
was compliant with antibiotics and dressing changes
(Image 1). His blood sugar was checked in clinic and
found to be over 500. Pt was admitted to the hospital
for IV antibiotics and surgical intervention.
Image 1
Image 2
Image 3
Image 4
Image 5
Image 6
Image 7
Image 8
Diagnosis- Diabetic necrotizing infection.
Treatment and Outcome- On admission labs where
drawn and pt had a WBC of 11.9 and his HgbA1c was
17.8. Pt was started on Vancomycin and Zosyn and a
wound culture was taken. 2 days after admission pt
underwent his first I&D (Image 2). After another 2
days the pt underwent his 2nd I&D and a wound
vacuum was placed intra-operatively (Image 3).
Conclusions
Early diagnosis of the disease, aggressive and timely surgical management, and broad
spectrum antibiotic therapy all has an impact on a diabetic patient’s outcome with
necrotizing fasciitis.
References
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